Flaherty, A.G., Sege, R.D., Griffith, J., Price, L.L., Wasserman, R., Slora, E., et al. (2008). From suspicion of physical child abuse to reporting: primary care clinician decision-making. Pediatrics, 122(3), 611-9.
Physicians in North America are legally mandated to report suspected child abuse (CA) to child welfare authorities (CWA). However, previous retrospective studies have shown that they sometimes fail to do so and report numerous barriers to reporting including lack of training, personal attitudes, negative experiences with CWA, time constraints, and fear of being involved with the court system. This study, is the first prospective study of its kind to address the following questions: (1) How frequently do clinicians report suspected CA? (2) At what levels of suspicion do clinicians report? (3) What factors influence reporting to CWA?
Of the 327 participants, 75 reported one or more injuries with suspicion of physical abuse to CWA, while 232 did not. Overall, clinicians had some degree of suspicion that 10% (168) of the cases they evaluated were caused by physical child abuse; however, of the 1683 injuries, even fewer, 95 (6%), were reported to CWA. Clinicians did not report 27% of the injuries that were rated very likely or likely caused by physical child abuse nor did they report 76% of injuries considered possibly caused by CA. Injuries were more likely to be reported when the injury was inconsistent with patient history, the referral included the question of possible CA, and the injury was more severe. Clinicians who, over their career, had failed to report at least one suspected case of CA or who had lost a patient/family because of reporting were more likely to report suspected CA. Race was not related to reporting decisions in cases involving families who had public health insurance, however injuries in African-American children were more likely to be reported when the family also had private health insurance.
These results suggest that the level of suspicion of abuse is not the only factor considered by clinicians when deciding whether to report a suspicious injury. The authors speculated that clinicians may, based on previous experience, report only those cases in which they believe CWA will take action (i.e., more severe cases). This could lead to overlooking chronically physically abused children with frequent, yet less severe injuries. Overall, this study sends a strong message: primary care clinicians often do not fulfill their legal requirement to report suspected child abuse injuries and a variety of factors contribute to the lack of reporting of physical child abuse. Further research is needed to clarify the reasons for this and to determine whether there are methods to improve clinician reporting behavior.
This study, using data from the Child Abuse Reporting Experience Study (CARES), was the first prospective observational study that examined primary care clinician physical abuse reporting frequency, suspicion levels, and other correlational factors. Two American national practice based research networks (PROS and NMAPedsNET) were used to invite1694 primary care clinicians from 748 practices to participate. Of these, 511 agreed to participate, 434 clinicians completed the study, but data for this study were limited to the 327 clinicians who indicated that at least one child they evaluated had an injury consistent with CA. Clinicians completed a short survey about past experience with CWA, education, attitudes, and practice environment. They completed Injury Encounter Cards (IECs) for any patient with an injury, whether or not the injury was the presenting issue. The IEC cards included 7 patient-related response items and 7 decision making factors. The completion rate, while quite low, may be considered reasonable given that doctors are especially busy and this study relied on the completion of several forms to gather the prospective data. Additionally, the possible effect of participants’ specialization remains unclear; clinicians who agreed to participate may have had more time, interest, and experience in the topic of CA, all of which could bias the findings. Since this study was completed in the United States, it is unclear how the findings apply to Canada’s context.